Summary
A recent national poll of 415 doctors authorized to prescribe buprenorphine for opioid addiction has found that many physicians are confronting obstacles to the use of this newly available medication. Inadequate access to the medication, poor awareness within the health community, costs, and federal limitations were among the most commonly cited hindrances.

Doctors aren't the only ones who may experience barriers to buprenorphine therapy: patients themselves may find obstacles when they seek office-based treatment. Almost 10% of the physicians could not be reached using the information provided in an online database meant to help new patients find them.

Despite the problems mentioned, the physicians overall were very enthusiastic about buprenorphine treatment and its future prospects.

Background
In October, 2002, the prescription drug manufacturer Reckitt Benckiser received approval from the Food and Drug Administration to market Subutex® and Suboxone®, buprenorphine and buprenorphine/naloxone products used to treat addiction to opiates such as heroin or prescription analgesics. With the approval of these buprenorphine products for outpatient treatment, individuals now have another potentially valuable treatment modality at their disposal. But if patients do not have viable access to these medications, the benefits, no matter how large, are ineffectual.

To learn about the availability and use of buprenorphine following the FDA's approval of office-based treatment, Join Together polled physicians from across the nation who are qualified to prescribe buprenorphine for addiction treatment. We were interested in finding out directly from authorized physicians what barriers, if any, are preventing further use and what have been their overall impressions and experiences.

There are currently several thousand doctors in the United States who are qualified to treat patients with buprenorphine; the poll focused on those physicians listed in the online directory maintained by the Substance Abuse and Mental Health Services Administration (SAMHSA). Earlier this year, the SAMHSA Buprenorphine Physician Locator database included contact information for 863 doctors from across the country.

We initially contacted or attempted to contact the physicians by phone; subsequent efforts were made via phone, email, and fax. After one month, 415 of the 863 doctors had been polled, producing a response rate of about 48%.

An important footnote about reaching these physicians: Nearly ten percent of the providers listed in the directory could not be reached, even with multiple attempts. In some cases, they had moved or died; in other cases, they had left the practice and office staff would not say how they could be contacted. Sometimes, the phone number was simply incorrect or disconnected. In addition, when the purpose of the poll was stated, on numerous occasions office staff denied that the physician provided buprenorphine, or had "those people" as patients. Those seeking to become new patients may have to surmount the initial obstacle of simply reaching the doctor

What We Asked the Physicians
After verifying that the respondent was qualified to prescribe buprenorphine for opioid addiction treatment, we asked the physicians whether they were having any difficulty finding a local source for the medication. Of the physicians who had already treated or tried to treat patients with buprenorphine (66% of those polled), one-third (33%) reported experiencing problems with access to the medication; the other two-thirds (67%) reported no such difficulties.

We then asked the physicians which forms of the medication they have prescribed. Eight percent of respondents had exclusively treated patients with Subutex® (buprenorphine only); 35% had only prescribed Suboxone® (buprenorphine/naloxone in combination); and 23% had prescribed both. Thirty-four percent had not yet treated patients with either medication.

Comments Reveal Detail About Obstacles
We did not explicitly solicit comments beyond the answers to the brief poll questions, but did record them when offered. Most of the comments described various difficulties physicians have encountered in prescribing the medication -- the most common complaint being that doctors could not find a pharmacy that would stock the drug. Some doctors said that obtaining buprenorphine is not a problem at most major chains in urban areas, but it can be much more challenging at smaller local pharmacies. Several respondents said there is a need to educate pharmacists to help them have accurate information about the drug.

Cost was another pressing issue of concern. Many doctors contended that lack of insurance coverage for buprenorphine treatment -- whether private, Medicaid or Medicare -- is perhaps the most substantial impediment to widespread use of the medication. Physicians have found that patients discontinue use of the drug because they cannot afford the treatment without adequate insurance coverage. Several respondents said that the cost is so prohibitive that some patients are forced to cease treatment, and then resume opiate use. One doctor implored, "Are insurance companies so blind that they can't see the savings of $20 a day for medication as opposed to $400,000 for a liver transplant?"

Other frequently mentioned barriers to extended use included established protocols, hospital regulations, buprenorphine exclusion from certain formularies (especially the Veterans Administration), differential access to Subutex® and Suboxone®, and the federally imposed limit that proscribes practices from treating more than thirty patients at a time. One frustrated doctor asked, "Why am I limited to thirty patients? I don't know of any surgeon who is limited to thirty operations a year!"

Despite these criticisms, a majority of doctors offered praise for the medication and seemed optimistic about further use. As one physician said, "It's not for everyone, but it's a miracle." Access to buprenorphine may be improving as well. While 34% of respondents said they had not yet prescribed the medication, a large number of these doctors indicated that they planned to start treating patients with the drug soon.

More Information

• Download a more detailed report of the poll questions, responses and comments
  
  
• Buprenorphine "Hot Issues" Resources Page

Special thanks to Rice University intern Mary Catherine Dillman, who helped coordinate the poll and write the results. Additional thanks to our pollsters, Marc Belanger (Join Together), Jen Eident (Hamilton College), Leah McDonald (Harvard College), Alfee West (Join Together) and Sarah Witham (Join Together and Boston University School of Public Health), and to Stela Bivol (Boston University School of Public Health), who analyzed the results.

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